Shoulder Dystocia (Green-top Guideline No. 42)

This guideline reviews the evidence regarding the possible prediction, prevention and management of shoulder dystocia.

This is the second edition of this guideline, which was originally published in 2005.

The third edition of this guideline is currently in development.

Update February 2017: Following a review of all guidelines in December 2016, some minor editorial changes have been made to this guideline since the original publication. The version available here is the most up to date. The date on the guideline has not been changed since no amendments were made to the content.

Update December 2014: New evidence and guidance in this field were reviewed in 2014 and it was decided that revision of this guideline would be deferred to a later date. The version available on the website and app will remain valid until replaced.

Shoulder dystocia is defined as a vaginal cephalic delivery that requires additional obstetric manoeuvres to deliver the fetus after the head has delivered and gentle traction has failed. An objective diagnosis of a prolongation of head-to-body delivery time of more than 60 seconds has also been proposed, but these data are not routinely collected. Shoulder dystocia occurs when either the anterior, or less commonly the posterior, fetal shoulder impacts on the maternal symphysis, or sacral promontory, respectively.

There is wide variation in the reported incidence of shoulder dystocia. Studies involving the largest number of vaginal deliveries (34 800 to 267 228) report incidences between 0.58% and 0.70%.

There can be significant perinatal morbidity and mortality associated with the condition, even when it is managed appropriately. Maternal morbidity is increased, particularly the incidence of postpartum haemorrhage (11%) as well as third and fourth-degree perineal tears (3.8%). Their incidences remain unchanged by the number or type of manoeuvres required to effect delivery. Brachial plexus injury (BPI) is one of the most important fetal complications of shoulder dystocia, complicating 2.3% to 16% of such deliveries.

The purpose of this guideline is to review the current evidence regarding the possible prediction, prevention and management of shoulder dystocia; it does not cover primary prevention of fetal macrosomia associated with gestational diabetes mellitus. The guideline provides guidance for skills training for the management of shoulder dystocia, but the practical manoeuvres are not described in detail – these can be found in standard textbooks and course manuals.